Monday, January 04, 2010

Not yet good enough

Here we are, at the start of a new year.  This seems to be a good time to take stock of things.  It has now been almost four years that my group started using an EMR.  My office is much further along for some things than I thought we would be by now, but also much behind for other things.

We have done well in terms of getting rid of paper inside the office.  We have no paper charts at all, and no filing cabinets for patient data.  All patient data is stored directly into the EMR, whether entered directly by someone in the office, or scanned in.  All members of this practice (physicians, Allied Health Professionals, staff) use the EMR.  Almost all tasks and patient-related communication are entered in the system.

We are efficient.  As of next Monday, I am on Open Access; my patients have all received a brochure outlining what this means (this was mailed in October).  We have eliminated delays and waiting times to see me are now essentially 0 or 1 day. 

We are also effective.  We measure our quality monthly; 89% of diabetics in this practice have had an eye exam in the past two years, and 91% have had a foot exam in the past year.  We have consistent alerts and reminders for  overdue services, and are always looking for ways to improve quality.

Through QIIP, we were provided with a spreadsheet outlining how many visits were expected for a patient in each age group, for a family physician on capitation or fee for service.  I had 3709 encounters for a year; expected for my practice is 4301, a difference of 592 encounters (13.8% less than expected).

While this does not tell me what exactly is contributing to the difference, some of the effect may be due to:
  • "max-packing" visits (doing everything that needs to be done in a single visit)
  • increasing time between repeat visits if appropriate
  • phone management
  • use of email with patients
  • Allied Health Professionals and team-based care; task distribution
  • working to top of scope for all team members 
The monthly number of visits appears to have decreased since September, from about 290 per month to 220 per month.  The number of "no shows" has decreased from 20 to 10 per month, and was down to 3 in December.  It may be fair to expect the difference between expected visits and booked visits to be larger by next year.

And yet, it does not seem to be good enough; we continue to suffer from systemic inefficiencies.  The number of proprietary referral forms has not diminished; there is no electronic prescribing in my neck of the woods; email communication between doctors and patients continue to be poorly supported by our health and privacy organizations; and worst of all, the onslaught of non-electronic incoming patient data has not abated one bit since we started.  Not one of the paper based reports that we started scanning four years ago have been switched over to electronic format (hospital, Diagnostic Imaging, specialist reports, non electronic laboratories); all these continue to be reported on paper.

The new funding for EMRs will make a big difference in adoption; I think the majority of family physicians are now considering switching to EMR.  The funding is also available to specialists, and I think they will switch as well.  Perhaps this will provide enough "push" for the system to integrate at last; labs that do not transmit reports electronically may well see a significant hit to their business, as physicians actively drive patients away from those facilities. 

We are pushing ahead with practice redesign.  On the agenda for this year is Group Medical Visits, where several patients with a similar condition (for example, diabetes) are seen together; our clinical pharmacist is in charge of arranging this.  My secretaries are now routinely collecting email addresses from all patients.  I have configured Outlook Express on every computer in the practice with my office email (, outgoing only.  If the secretary has trouble reaching a patient by phone, she sends an email asking them to call back, or sends the date of the appointment and asks for a phone call to confirm.  One day we'll have online booking for patients.  Incoming email to the office address gets redirected to our office manager, and she then takes action or forwards to the physician if appropriate.  I have been told by eHealth Ontario that they are looking at the possibility of giving patients access to the secure OneMail; as well, they are considering adding pharmacies to OneMail--that would be good, perhaps the pharmacist could email me if they have a question, instead of faxing or calling.  Perhaps I could even send prescriptions via secure email instead of fax. 

I think we have made progress in re-engineering how we look after patients in this office, but I'm ambitious.  I don't think it is good enough yet. 



Anonymous said...

Hi Dr. Greiver,

Many thanks for continuing to publish your excellent blog. I think the metrics info on your practice is a great step forward to improving the quality of care for patients.

The outstanding issue I see is the total number of encounters per year (knowing that you work part-time). I think one of the major problems with EMR in general is that it will slow most physicians down to the point where they either can't make enough money or the system will require more doctors enrolled in a capitation model like an FHT/FHO etc. I know of many FFS primary care physicians that see over 80 patients per day and some see more than 100 per day (20,000+ encounters per year). Could the Ontario healthcare system afford to have all 11,000 primary care physicians using EMR today?

Will/can quality of care improvements necessarily reduce the total number of patient encounters to make up for the aforementioned slowdown most doctors find when using a comprehensive EMR system like your group?

Your thoughts on this issue would be great.


Michelle Greiver said...

Thank you for your thoughtful comments. I admit that I have considered stopping this blog; I don't really know if there is value to doing this, and most of the initial implementation issues internal to the office have been worked out.

Your comment is with regards to efficiency. You are correct, the EMR decreases "visit" efficiency, at least initially; visits take longer, charting takes longer, and it takes an inordinate amount of physician time to enter the initial data that is transferred from the paper chart.

I do not think that EMR decreases visit length, or the amount of time spent charting for the majority of physicians. If efficiency is defined by those measures, then having an EMR does not make a physician more efficient.

I took my data on visit numbers from the spreadsheet supplied by ICES; this is derived from OHIP (our provincial health insurance), and reflects average number of visits for a physician with the same age/gender practice as mine, practicing in a Family Health Team. The spreadsheet shows that physicians in Fee for Service bill for more visits for the same practice profile--they see their patients more often.

FFS rewards you for seeing more patients at the office. The EMR will decrease the number of those visits by slowing you down, and will negatively impact FFS (at least initially).

If a physician sees 80 patients per day, and works an 8 hour day (9 hours, 1 hour lunch), then that is 10 patients per hour, including charting--6 minutes per patient. The average length of consultation in family practice varies, but is generally 10 to 15 minutes of direct contact; 17 minutes here: Annals of Family Medicine 3:494-499 (2005). Average work week: 50 hrs (National Physician Survey 2004). The 80 patient per day physician exists, but is atypical and not representative of our profession. I can see 10 patients per hour when I work in our After Hours walk in Clinic and in no other setting.

The efficiency within the EMR comes from being able to do more per visit, and to do more outside of visits (example, assigning tasks to staff such as calling patients to inform them of normal results). As well, I can see if there are additional future appointments as soon as I load the chart, and I address these at the current visit--therefore making the additional visit unnecessary.

I am more efficient because I can do more per visit and I can do more outside of visits. This is related to the EMR (point of care reminders, alerts, electronic assignation of tasks). It decreases patient demand for visits while maintaining quality. If I was on FFS, then I would be getting paid less; being on capitation means that I am rewarded for this. Therefore, I can eliminate waiting times for my patients to see me (today it was zero days), or I can increase my roster size by taking on new patients.

Neither FFS nor capitation addresses quality of care.

The EMR can make you more efficient in the alternative way I have described. However, this efficiency is rewarded only if a physician switches over to a capitated system of payment. I am not saying that FFS is a bad system, but I am saying that you get the system you plan for.

If physicians become more efficient, then we can take on more patients in our practices. Whether the health care system can afford this under capitation is another question which I cannot answer.

EMRs are immature, and the switch is in the early stages for most of us. I think we're still quite a long way from "type B" efficiency in most practices. You are seeing an early adopter at work.


Jean-François Rancourt said...

Michelle, I read your blog each month. It's help me a lot in our EMR.

Can you send me some information to learn about Advance Access. Nobody have implemented it in Québec and I want to try it but with a fine preparation.
Thank you

Michelle Greiver said...

Jean-Francois, please send me your email address (to I will forward you the information.


Ronak Patel said...

Hi Dr. Greiver,
Since you have an established clinic with an EMR syste I would like to get your insight on what the next steps would be for a clinic like yours when dealing with labs, pharmacies and other clinics who are still in the paper world.

I look forward to your thoughts on the matter.

EMR Implementation said...

Thanks for sharing this info.

John Currie said...

Dr. Griever, great blog, thank you for sharing your journey transitioning to EMR.

Eric 'EMR' Fishman, MD said...

We've been following the progress towards implementing an EMR for quite a few years, and you have documented this extraordinarily well.

Resources for others include to determine readiness and then to assist with selection.

And, again, congratulations on your journey!